Skip to main content

A Near Miss ‘Never Event’: A Truly Futile PEG Tube

Photo Credit

I barely escaped from an embarrassing situation recently in the hospital. I was consulted to place a feeding tube, called a PEG, in an ICU patient. We gastroenterologists are rarely consulted for our opinion on whether these tubes make sense, which they often don’t. We are recruited to these patients simply to perform the technical function of inserting the tubes, so that Granny, or Great-Granny, or Great-Great… , won’t starve. Multiple medical studies have demonstrated that providing this nutrition to individuals with advanced dementia doesn’t benefit them. In addition, while it may seem intuitive that artificial feeding provides comfort, this may not be the case. It may provide more comfort to the physicians and family than it does to the patient.

The above paragraph is not a rigid presentation. Obviously, the decision to place and accept a feeding tube must be individualized. Regardless, it is inarguable that too many of these tubes are being placed for the wrong reasons.

An ICU nurse contacted me to place a feeding tube in one of her patients. There was a large group of visitors hovering around the bedside. As is every physician’s custom, I asked the nurse to summarize the patient’s hospital course and the active medical issues. The consulting physician had requested a PEG feeding tube and a tracheostomy tube. This latter tube is inserted surgically into the windpipe and is connected to a ventilator. (Patients who cannot be weaned off of respirators often have these ‘trach’ tubes inserted as the original breathing tubes cannot remain in the throat beyond a few weeks.) I asked how long the patient had been on a ventilator, and she replied that she was breathing on her own. Even a concrete thinking gastroenterologist thought it was odd to place a ‘trach’ tube in a patient whose own lungs apparently were functioning adequately. This would be analogous to placing a PEG tube in a patient who had just supersized his fast food order.

While this scenario never achieved ‘never event’ status, it does illustrates how medical mistakes can happen. The consulting physician confused two of his patients. The patient assigned to me needed neither a PEG nor a trach, but one of her neighbors did. I was relieved that I didn’t enter the patient’s room to discuss the pros and cons of feeding tubes to the large group assembled there. What if I did enter the room and there were no visitors? What if the patient was demented and wasn’t eating well? One can imagine how a ‘never event’ can happen, especially if necessary safeguards and checks are bypassed or ignored.

I have already expressed in a prior post about why unnecessary PEG tubes are placed. I left one reason off the list. Luckily, it didn’t happen in this case.

Comments

  1. It wasn't a close call. We may be asked to do technical stuff but we're still not relieved of our responsibility to perform an H&P, although Medicare might not have paid you for it.

    There are questions that never seem to be asked in these situations. What was going on in the nurse's mind? Did she have too many patients because of staffing problems? Was she exhausted from working a long arduous shift? Was she preoccupied because her husband filed for divorce or her son just got it with a possessions charge? Did she have so much seniority that she just doesn't give a rip anymore?

    I doubt the last one, as the ICU isn't typically a good place to ride out one's career.

    Non-medical folks and some harsh critical medical types would just assume she was an evil incompetent person. Odds are she's not.

    ReplyDelete
  2. Thanks for the comment, AB. The attending goofed and the nurse didn't question an order that made no sense. Thus, begins a cascade that can lead into the Canyon of Never Events.

    ReplyDelete

Post a Comment

Popular posts from this blog

Why Most Doctors Choose Employment

Increasingly, physicians today are employed and most of them willingly so.  The advantages of this employment model, which I will highlight below, appeal to the current and emerging generations of physicians and medical professionals.  In addition, the alternatives to direct employment are scarce, although they do exist.  Private practice gastroenterology practices in Cleveland, for example, are increasingly rare sightings.  Another practice model is gaining ground rapidly on the medical landscape.   Private equity (PE) firms have   been purchasing medical practices who are in need of capital and management oversight.   PE can provide services efficiently as they may be serving multiple practices and have economies of scale.   While these physicians technically have authority over all medical decisions, the PE partners can exert behavioral influences on physicians which can be ethically problematic. For example, if the PE folks reduce non-medical overhead, this may very directly affe

Should Doctors Wear White Coats?

Many professions can be easily identified by their uniforms or state of dress. Consider how easy it is for us to identify a policeman, a judge, a baseball player, a housekeeper, a chef, or a soldier.  There must be a reason why so many professions require a uniform.  Presumably, it is to create team spirit among colleagues and to communicate a message to the clientele.  It certainly doesn’t enhance professional performance.  For instance, do we think if a judge ditches the robe and is wearing jeans and a T-shirt, that he or she cannot issue sage rulings?  If members of a baseball team showed up dressed in comfortable street clothes, would they commit more errors or achieve fewer hits?  The medical profession for most of its existence has had its own uniform.   Male doctors donned a shirt and tie and all doctors wore the iconic white coat.   The stated reason was that this created an aura of professionalism that inspired confidence in patients and their families.   Indeed, even today

Electronic Medical Records vs Physicians: Not a Fair Fight!

Each work day, I enter the chamber of horrors also known as the electronic medical record (EMR).  I’ve endured several versions of this torture over the years, monstrosities that were designed more to appeal to the needs of billers and coders than physicians. Make sense? I will admit that my current EMR, called Epic, is more physician-friendly than prior competitors, but it remains a formidable adversary.  And it’s not a fair fight.  You might be a great chess player, but odds are that you will not vanquish a computer adversary armed with artificial intelligence. I have a competitive advantage over many other physician contestants in the battle of Man vs Machine.   I can type well and can do so while maintaining eye contact with the patient.   You must think I am a magician or a savant.   While this may be true, the birth of my advanced digital skills started decades ago.   (As an aside, digital competence is essential for gastroenterologists.) During college, I worked as a secretary